Developing professional attitudes in training: report from the AMEE Berlin professional development workshop group

This workshop ran fully subscribed in Berlin, was so well supported that an emailing discussion list is to be set up (thanks to AMEE and Peter Toon), and a follow-up workshop has been accepted for Lisbon in 2002. The keynote address outlined why the public and health professionals should be concerned about development of professional attitudes in training, what educational reforms are trying to achieve, how attitudes can be influenced through educational processes, and how outcomes can be evaluated. The participants opted to focus discussion on the key areas of what learning methods would be most effective, and how to assess attitudes in a meaningful and valid way. This paper presents the keynote and main points from discussion for interest and further collaboration. Attitudes are on a spectrum, more stable than opinions but less so than personality traits. They can only be estimated by our behaviours or statements but this does allow learning objectives to be set: an example might be ‘will show care equally for patients without discrimination as to race, religion or cultural background’. The cause for concern about whether medical education and training achieves appropriate attitudinal development stems from critical incidents of major unprofessional behaviours (Pringle, 2000), changing public expectations (Anderson & Florin, 2000), and evidence that student attitudes may actually be adversely affected during training (Becker et al., 1961; Rezler, 1974) unless a more directive curricular approach is adopted. There is a strong professional and public consensus around the goals of attitudinal development (GMC, 1993), examples of which are given in Box 1. The educational processes shown to underpin such development are not in the didactic lecture mode, but require working with the student as a person, encouraging his/her views and experience to become an explicit part of their learning. The following have been effective: using near-life ‘thick description’ examples that explore ethical dilemmas or complex decision making; explicit exploration of the needs of groups that are vulnerable, preferably linked with input by representatives of such groups; ensuring that all assessments include attitudinal objectives; and use of simulated patients in skills-based work to underpin rehearsal of options in a ‘safe’ environment, whilst modelling desirable outcomes (Maudsley & Strivens, 2000). All these allow the learners to be exposed to challenge in a peer-influenced but managed environment, where personal assumptions and unstructured knowledge can be brought into a consciously critical professional domain (Eraut, 1994). The wider ‘culture’ of the learner has also been shown to be important: good role models, supporting the student to be self-questioning and constructively challenging, and enthusiastic tutors who like and motivate students (rather than criticize or humiliate). Attitudinal objectives need to be embedded in all learning including clinical placements (J. Gordon, personal communication), rather than being taught as a stand-alone ‘course component’, which distances the learner from engagement as an individual. Facilitated reflection is key (Boud et al., 1993), and explicit in this is the need for suitably skilled tutors to assist students in exploring their own uncertainties. Having set up new aspects of curriculum, models of assessment are also needed: instrumental checklists are less valid than observations of behaviour, tutor and staff/patient feedback, written reflective pieces such as critical incident